Humeral shaft fracture with brachial artery injury

The management of ten patients with fracture of the humeral diaphysis and concomitant injury to the brachial artery was analyzed retrospectively for examination of the factors contributing to preservation of limb viability and function. Of ten treated fractures, eight were rigidly stabilized with either a plate or an external fixation device. Seven of the vascular injuries required an interpositional graft. Three arteries were repaired with an end-to-end anastomosis. Two of these repairs failed in patients whose fractures were not rigidly stabilized, and one of these patients required amputation. Fasciotomy was performed in five cases. Seven patients retained normal or functional extremities despite ligation of the brachial artery in two individuals. Preoperative arteriography was of equivocal value, and it doubled the patient's transit time from the emergency room to surgery. The use of a temporary intraluminal vascular shunt to perfuse the limb at surgery and the semi-invasive rigid stability afforded by contemporary external fixators are important advances in the management of these complex injuries. In civilian practice, the prioritized guidelines the authors suggest for care of combined major skeletal and vascular trauma to the arm are: resuscitation of the patient; arteriogram, which is nonessential in open injuries but helpful in closed trauma; intraoperative perfusion of the limb with a temporary shunt; rigid bony stabilization; wound debridement; vascular repair with an autogenous vein graft; neurorrhaphy; and assessment of the need for fasciotomy.